What are the treatment options for eczema?

Treatment Options for Eczema

Topical corticosteroids are the first-line treatment for eczema flare-ups, with potency selection based on severity and location, while daily emollient therapy forms the foundation of maintenance care. 1

First-Line Treatments

Emollients and Moisturizers

• Apply fragrance-free emollients 3-8 times daily, even when skin appears normal 1
• Apply immediately after bathing to lock in moisture
• Ointments provide maximum occlusion (best for very dry skin)
• Creams offer a good balance of hydration and acceptability (less greasy)
• Emollients should be the foundation of all eczema management plans

Topical Corticosteroids (TCS)

• Potency selection based on location and severity:
  • Medium-potency: For body areas
  • Low-potency: For face, neck, and intertriginous areas 1
  • Potent TCS are more effective than mild TCS for moderate to severe eczema 2
• Application frequency:
  • Once-daily application is as effective as twice-daily for potent corticosteroids 1, 2
• Duration:
  • Use low-potency TCS for short periods (<2 weeks) 1
  • Limit use of medium-potency TCS to 4 weeks 1
• Safety considerations:
  • Risk of skin thinning increases with potency but is rare (1% of cases) when used appropriately 2
  • Long-term intermittent use of mild/moderate TCS likely has minimal risk of skin thinning or growth abnormalities 3

Topical Calcineurin Inhibitors (TCIs)

• First-line options for sensitive areas:
  • Facial atopic dermatitis
  • Intertriginous areas
• Do not cause skin atrophy, making them preferable for long-term use 1
• Pimecrolimus (Elidel) and tacrolimus are effective options
• Pimecrolimus achieves 71% clearance or near clearance after 8 weeks 1
• Important safety information for pimecrolimus (Elidel): 4
  • Not for continuous long-term use
  • Not for children under 2 years old
  • Use only on areas with eczema
  • Apply a thin layer twice daily

Second-Line and Advanced Treatments

Infection Prevention and Treatment

• For signs of infection:
  • Use antiseptic washes with aqueous chlorhexidine 0.05% 1
  • Consider bleach baths with 0.005% sodium hypochlorite twice weekly 1
  • Use oral antibiotics if clinically indicated (e.g., doxycycline 100mg twice daily for 6 weeks) 1

Maintenance Therapy to Prevent Flares

• Weekend therapy (proactive approach):
  • Apply TCS twice weekly to previously affected areas
  • Reduces likelihood of relapse from 58% to 25% 2
  • Continues even when skin appears normal

Phototherapy

• Consider for moderate to severe cases not responding to topical treatments
• Narrowband UVB generally preferred for adolescents 1
• Should be administered under specialist supervision

Systemic Therapy

• For very severe, refractory cases, refer to dermatologist for consideration of:
  • Dupilumab 1, 5
  • Short courses of oral corticosteroids (<7 days) for severe acute flares 1

Lifestyle Modifications

• Use gentle, pH-neutral synthetic detergents instead of soap 1
• Avoid irritants such as perfumes, deodorants, and alcohol-based lotions
• Identify and eliminate triggering substances
• Avoid irritant clothing and extremes of temperature
• Keep nails short to minimize damage from scratching 1
• Consider air purifiers to reduce PM 2.5 exposure, especially during dry weather 1

When to Refer to a Specialist

• Diagnostic uncertainty
• Poor response to first-line treatment after 2-3 weeks
• Need for second-line treatments
• Very severe or widespread disease 1

Common Pitfalls to Avoid

1. Underuse of emollients - They should be applied multiple times daily, even when skin appears normal
2. Overuse of topical corticosteroids - Use appropriate potency for location and limit duration
3. Inappropriate potency selection - Using high-potency TCS on face or intertriginous areas
4. Neglecting infection - Secondary infections require specific treatment
5. Oral antihistamines - Not recommended as they do not reduce pruritus 5
6. Continuous use of TCIs - Should not be used continuously for long periods 4